|
Take a look at our Q&A for some of the most commonly asked questions about Two-Way Pricing and the Maximum Plan Allowance (MPA).
If you have additional questions, please email the Professional Services Department at
Profservices@ddpco.com.
1. What is Two-Way Pricing?
Two-Way Pricing is a methodology used by Delta Dental of Colorado (DDCO) for reimbursement of claims processed from participating
and nonparticipating providers treating members of Delta Dental Premier groups. With Two-Way Pricing, payment is made based on the
Approved Amount for a procedure. The Approved Amount is the lesser of the dentist's submitted fee or the Maximum Plan Allowance (MPA)
fee for the procedure performed. For participating providers, any difference in fee between the dentist's submitted fee and the MPA
fee is not chargeable to the patient.
Example 1 (for illustrative purposes only) Dentist charges a fee that is greater than the MPA fee:
| Procedure Code |
Submitted |
Approved |
Not Chargeable to Patient |
| D2750 - Crown |
$1000 |
$900 |
$100 |
Example 2 (for illustrative purposes only)Dentist charges a fee that is less than the MPA fee:
| Procedure Code |
Submitted |
Approved |
Not Chargeable to Patient |
| D2750 - Crown |
$800 |
$800 |
$0 |
2. How is the MPA fee for each procedure established?
The State of Colorado is divided into two (2) regions based on an analysis of population and economic data.
The fees charged for treatment completed during a 12-month period are compiled from claims submitted by all
dentists within the same region. Those fee data are used to establish a participating and a non-participating
Maximum Plan Allowance (MPA) fee for each procedure for that region. We also review dental fees on a regional
and statewide basis to ensure DDCO remains in a competitive position.
The Maximum Plan Allowance data is confidential. When a claim is submitted for completed treatment, payment is made
based on the lesser of the submitted fee or the MPA fee for the procedure. The Claim Payment Statement (CPS) notifies
you of the reimbursement on a claim.
MPA fees are reviewed annually and adjusted as necessary to reflect inflation and changes in the marketplace.
3. Does the MPA reduce reimbursement rates for most dentists?
No. The MPA establishes a fee structure that is based on what the majority of dentists within the same region charge for a particular service. Only those dentists with the highest fees will see a reduction in reimbursement.
The MPA is designed to achieve the following:
- Provide fair reimbursement to the professional community
- Demonstrate our commitment to providing affordable dental coverage
- Maintain our competitive position in the marketplace
- Strengthen our subscriber base which in turn supports our strong provider network, and the products and services we can offer
4. Does Delta Dental of Colorado use the reimbursement rates from Delta Dental member companies in other states in establishing the reimbursement rates for the Colorado MPA?
No. The Colorado MPA fees are calculated based on Colorado's claims experience, and the charges submitted from dentists within the same region for the same procedure code over a 12-month period.
5. Why does Delta Dental of Colorado ask dentists to sign a contract adhering to the MPA without giving details about the cost structure?
We looked at this issue closely, and ultimately the Delta Dental of Colorado Board of Trustees made the decision to withhold disclosure of these cost details based on the recommendation of a board committee. Several dentists sat on that committee and joined with its non-dentist members in making that recommendation.
The committee based its recommendations on several factors. First, disclosing these rates would have raised legal issues related to anti-competitive behavior. Second, it was important to put in place a cost structure that was fair to both dentists and patients. For dentists, the MPA meets this objective by basing the MPA fees on what the majority of dentists within the same region charge for a particular service. Third, the Board did not think it was appropriate for an insurance company to distort the pricing system for dentistry, which is what would have happened if Delta Dental published a schedule of fees. Instead, the Board determined it would be best to let dentists run their businesses and value their services as they saw fit.
6. Why doesn't Delta Dental of Colorado allow dentists to balance bill?
We understand this is frustrating for many dentists. We don't allow balance billing for one important reason -- it costs more for our customers. Members -- and their employers -- are clamoring for some control over health care costs, including dental costs, and not allowing balance billing is one of the ways in which Delta Dental responds to that need. By keeping dental care costs affordable for our members, we are working to increase the patient base enjoyed by all our network providers.
|
